This questionnaire must be completed by an individual knowledgeable about the employee’s or prospective employee’s work assignment, including the technical nature of the work as well as the source of the financial support. Questions regarding the completion of this form should be directed to the appropriate export control office (HSC or Central Campus). Return the signed and completed form to [select appropriate campus office]:

Health Sciences:
Tim Muller
Reginald Heber Fitz Hall, B61G
MSC08 4560
e-mail:
Phone: (505) 272-5993 / Central Campus:
1800 Sigma Chi NE
MSC05 3400
e-mail:
phone: (505) 277-2968
Employee or Prospective Employee Name:
Country of Citizenship or Dual Citizenship :
Department:
Federal regulations for visa applicants of this type require UNM to certify that the employee or prospective employee either: (1) will not be involved in any activity that would require an export control license; or
(2) will be involved in an activity requiring an export control license and UNM will prevent access to controlled technology until an export control license has been obtained.
Please respond to the questions below as they relate to work that the employee or prospective employee will perform at the University and then sign the form at the bottom. In addition to completing this form, please providea current curriculum vitae as part of the review process.
  1. Describe the type of work or scientific research the employee or prospective employee will participate in. Changes regarding work assignments or scientific research projects must be reported to the appropriate export control office before implementation.

  1. Will the employee or prospective employee participate in any scientific research?
Yes or No (If “No” then skip questions #2- #6.)
  1. Provide the following information for each research project in which you know or anticipate the employee or prospective employee will participate.

  1. Name of Principal Investigator

  1. Job description of the employee / prospective employee

  1. Laboratories or work areas of campus

  1. Title(s) of sponsored research proposals/grants/awards

  1. PreAward number(s) and associated grant award number(s)

  1. Name of research sponsor

  1. Will the employee or prospective employee perform ALL of the following functions for any research equipment: operation, installation, maintenance, repair, overhaul and refurbishing?
Yes or No (If “Yes” then list the equipment.)
  1. Will the employee or prospective employee participate in any research under a research contract or grant that restricts certain non-US persons from participating in the research or accessing the research results (e.g., restriction on participation by individuals who are not US citizens or green card holders)?
Yes or No
  1. Will the employee or prospective employee participate in any research under a research contract or grant that restricts publication or dissemination of the research results (other than prepublication review by the research sponsor to insure that the publication would not inadvertently divulge proprietary information that the sponsor has furnished to the researcher)?
Yes or No
  1. Will the employee or prospective employee be exposed to encryption software source code, or otherwise be involved in the design, development, or production of encryption software?
Yes or No
  1. I will notify the appropriate Export Control office ( or ) before the employee or prospective employee works on undisclosed projects, moves to a different laboratory or begins work in a setting outside my control.
PI or Department Chair Name:
Department:
Title:
PI or Department ChairSignature______Date:
Internal Use Only – Export Control
Visual Compliance check
Other check
There are no apparent deemed export control concerns with the questionnaire.
Other:
Signature ______Date ______
Forwarding instructions
Forward the completed form to the PI or Department Chair and the Office of University Counsel (Kevin Gick, Assistant University Counsel [ and Laurel Smith [).

1Rev. 11/29/2018